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Integrating Acute and Post-Acute Care to Improve Outcomes
Session #146
February 13, 2019
Eva Bering, MSN, MHA , RN, NHA, Interim Director, Post-Acute Care Continuum, Lancaster General Health
Donna Ford, RN, Clinical IT RN, Landis Homes
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Eva Bering
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Donna Ford
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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• Creating an Integrated Care Network
• Narrowing Down Network of Post-Acute Providers
• Benefits of a Preferred Partner Network
• Understanding the Role of Post-Acute Providers
• Post-Acute Journey to Integrated Care
• Defining the Role of Care Transitions & Care Coordination
Agenda
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• Identify the technology components necessary to successfully
achieve outcomes-based reimbursement across care settings and
the degree of integration that must be achieved to create a true
value-based care solution
• Recognize and document the benefits of standardized care/clinical
plans for conditions such as congestive heart failure, pneumonia
and hip fractures that commonly require post-acute care
• Identify and measure the negative effects of transactional
information exchange during critical stages of care -- e.g., patient
intake and care transition
• Define specific stages in automating care coordination, with the
goal of shifting from a transactional perspective to a longitudinal
view of patient information
• Create a framework for a collaborative effort between acute and
post-acute providers that drives improved cost and quality
performance, and alignment on clinical initiatives
Learning Objectives
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• Accountable Care Organization (ACO)
• Participating in Medicare Shared Savings Program as well as
other value based reimbursement programs
• Working towards maximizing continuum management
• Taking varying stages of risk for total costs of care
Lancaster General Health
Community Care Collaborative (LGHCCC)
Clinically Integrated Network
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Structure of an Accountable Care
Organization (ACO)
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It Takes a Village to Care for a
Patient/Resident
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• Criteria
– Volume of discharges
– Participating payer plans
– Use of LGHP Medical Director
– Utilization of LGH Services including EPIC
– Geography – county coverage
– Willingness to be creative and engage in care transformation
– Overall 5 Star rating and quality rating
– Bed capacity and availability
• Scoring system where criteria was weighted and then top
performers were identified
Identification of PAC Preferred Partner
Network (PPN) Members
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Presentation Title Could be Placed Here | 10
ACO
Readiness Scoring
Facility
Discharge
Volume
CMS 5-Star
Rating
LGHP
A
LGHP
M
30-Day
Readmission
Rate
Clinical
Affiliation/
Participation
Bed Availability/
Capacity
Geograph
ic
Location
Total
Facility 1
1 4 0 0 2 1 1 NC 7
Facility 2
2 3 1 0 3 2 3 NC 14
Facility 3
1 4 1 0 4 1 C 11
Facility 4
5 1 1 2 3 4 5 C 21
Facility 5
1 5 0 0 1 1 2 NE 10
Facility 6
1 2 0 0 5 1 3 NE 12
Facility 7
1 5 0 0 3 3 NE 12
Facility 8
1 4 0 0 4 1 1 NE 11
Facility 9
2 1 0 0 2 2 3 C 10
Facility 10
2 4 0 0 3 2 3 C 14
Facility 11
1 2 0 0 3 1 3 SE 10
Facility 12
1 3 1 0 3 2 2 C 12
Facility 13
3 2 0 0 2 2 4 C 13
Facility 14
2 5 1 2 5 4 3 NC 22
Facility 15
1 5 1 2 4 3 3 NC 19
Facility 16
1 3 0 0 1 1 2 NW 8
Facility 17
5 2 1 2 1 4 3 C 18
Facility 18
1 4 0 0 1 1 1 NE 8
Facility 19
4 3 1 2 3 4 5 NW 22
Facility 20
3 3 1 2 3 4 3 C 19
Facility 21
2 4 1 2 4 4 3 NC 20
Facility 22
1 2 1 2 1 2 NE 9
Facility 23
2 4 1 2 3 2 3 NW 17
Facility 24
2 5 0 0 4 1 3 SE 15
Facility 25
1 2 0 0 4 2 1 NE 10
Facility 26
2 5 0 0 4 2 3 NW 16
Facility 27
2 2 0 0 4 2 3 NW 13
Facility 28
1 4 1 2 3 4 2 NC 17
Facility 29
4 4 1 2 3 4 4 SC 22
Facility 30
1 2 0 0 5 2 NE 10
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Post-Acute Preferred Provider Network
(PPN)
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• Reduced re-admission rates
– FY 16: 13%
– FY 17: 8.83%
– FY 18: 9%
– FY 19 (YTD): 8.7%
– Standardization of Care / Clinical Plans
• Fx Hip: LOS from 34 days to 17 days
• CHF: LOS from 28 days to 13 days
• Pneumonia: LOS 16 days
• Gunderson training for PPN partners – Advance Care Planning
• Standardized SNF application process
• Updated TOC document
• Concentrated Educational Programming
• 43% reduction in SNF cost and utilization in last ACO performance year
PPN Accomplishments and Outcomes
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Post-Acute Preferred Provider Network (PPN)
• Benefits of Network Participation for SNFs and LG
• Improved performance
• Discharge Planning/Plan of Care
• Quality meeting engagement
• Data sharing tool
• Educational opportunities
• Bed availability for LG patients
• Marketing as applicable and appropriate
• Improved referral processes
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• 114 Acre CCRC Campus
• 875 Residents
– 103 SNF, 124 Personal Care, remaining in cottages and
apartments
• 550+ employees
• 5 Star Facility
• Part of Landis Communities
• One of 17 CCRC in the Lancaster County, Pa
Landis Homes
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• Reimbursement models are changing
• Length of stays are shorter
• Health systems narrowing networks
• Need to coordinate care upstream and downstream
Post-Acute Value-Based Care and
New Pressures
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• Improve quality of life
• Improve care coordination & data sharing capabilities
• Improved quality of care & outcomes
• Improve care transitions
• Reduce cost of care
Goals
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Competing For Referrals
Post-Acute
Providers
Lancaster General
Health
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The Journey to Integrated Care
Interoperability
Documentation
Exchange
Standardizing data transfer with
CCDs, labs, public health registries
and health information exchanges
Secure, Direct Exchange
Direct Message internally as well as
externally to the larger provider
community, enabling coordinated care
across the care continuum
Using a Certified EHR
Digitized but unconnected to the
larger provider community
Transitions of
Care
Point-to-point referrals
within a single workflow
Query-based Exchange
Find/request information from other
providers, such as discharge
summaries
Integrated,
Whole-person Care
Single patient record across
the entire continuum
Query for Key
patient information
6 Minutes vs. 29 hours
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If the Market is Shifting… What is Required?
Automated platforms that
integrate data to drive new
insights to the care TEAM
assigned to manage and
coordinate care for a
population
Providers must ask new
questions about clinical
and financial data and be
able to share and ACT on
that information in real-time
Tools designed to enable
views of the population in
new ways, with new
capabilities on creating
cohorts, and attributing lives
to ALL models of care
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Skilled Nursing Transitions of Care
C-CDA/Notes
Updated Post Acute data is shared
with the Hospital
Integrated Care Supported by Provider
Collaboration and Bi-directional Clinical
Data Exchange
Integrates the Hospital’s Patient
Data and Begins the Admission
C-CDA/Assessments/Notes
Patient is Referred to
Skilled Nursing
Clinical Services
performed at the
Skilled Nursing Facility
Landis Homes
Lancaster General Health
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Seamless Care Transitions
No duplicative data entry
No need for paper charts
Demographics
Doctor
Allergies
Related parties
Diagnosis
Unified resident/patient record
Care plan
Scheduling
Medications
Residential Living
Assisted Living
Skilled Nursing
Home Health and Hospice
Adult Day Care
Memory Care
ALL CARE SETTINGSPATIENT RECORD
Single, Unified Bill
Single Record
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Data exchange supports improved care coordination and minimizes risk
Care Coordination
Medication Reconciliation Between Organizations
Safety
50 percent of hospital-related medication errors and 20 percent of
adverse drug events result from poor communication at transition
60 percent of post-discharge adverse drug events could be
prevented or improved by better intervention
Efficiencies
Cost of reconciling medications without history
• 10 hours/$290
Cost with increased coordination between hospital and SNF
• 1 hour/$35
Patient Medications
30% 8+ medications
40% don’t understand side effects
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Shared Care Planning & Coordination System
Type
Shared Care
Planning Tool
Care Coordination &
Communication Tool
Direct Secure
Messaging
Integration of clinical pathways
(care protocols) and other
critical patient data
Electronic Referral
Management
Coordinate care both upstream
& down
Report outcomes data
Reduce Length of Stay
Reduce gaps in care
Integration to Health System &
Primary Care Providers
Participating in National Health
Data Sharing Frameworks
Supporting Industry
Interoperability Standards
Open Network supporting Fast
Healthcare Interoperability
Resources (FHIR) Application
Program Interfaces (APIs)
Coordinate care both upstream
& down
Report outcomes data
Reduce Length of Stay
Reduce gaps in care
